Background:The diabetic foot
abnormalities is clearly one of the most important complications of diabetes
mellitus (DM) and is the leading cause of hospitalization with substantial
morbidity, impairment of quality of life and engender high treatment costs.
The aim of this study was to estimate the prevalence of diabetic foot
abnormalities among patients with type 2 DM and the predictors of these
abnormalities in Basrah, Iraq.

Patients and Methods: This was cross
sectional study of patients attending the out patient clinic of two
hospitals in Basrah (the General and the Teaching) for the period from
January to the end of December 2005.All patients were having type 2 DM.

Results: The total number of patients
was 182 (80 males and 102 females. Diabetic foot abnormalities were reported
in 46.7% of patients. Most of patients were having more than one
abnormality. Structural foot abnormalities reported in diabetic patients
were prominent metatarsal heads in 36.2%, wasting in 11.5% hammer toes in
10.9%, pes cavus in 5.4%, claw toes in 3.8%, and amputees in 2.1%. While
skin changes includes dryness if the skin in 17%, fissures in the skin in
14.7%, callosities in 14.2%, Tinea pedis in 13.7%,foot ulcer in 13.7% ,and
nails changes in 7.1%. Peripheral neuropathy and dermopathy were seen in
21.9% and 6% respectively.

complications of diabetes
mellitus (DM) and is the leading cause of hospitalization with substantial
morbidity, impairment of quality of life and engender high treatment costs.1,2
It not only occurs as a typical complicationin the
late stages of diabetes but also in patients with newlydiagnosed DM.

Motor neuropathy leads to muscle atrophy, foot
deformity, altered biomechanics of walking, and redistribution of foot
pressures during standing and walking lead to callus.

3,4
Abundant callus formation on pressure points(which acts like a foreign body
and further increases pressure) together with thinning of the submetatarsal
head fat-pads, additionally increases the force of plantar pressure and
ultimately results in foot ulceration .

The risk of ulceration is proportional to the
number of risk factors. The risk is increased by 1.7 in persons with
isolated peripheral neuropathy, by 12 in those with peripheral neuropathy
and foot deformity and by 36 in those with peripheral neuropathy, deformity,
and previous amputation, as compared with persons without risk factors.

5

In developing countries, which will experience
the greatest rise in the prevalence of type 2 DM in the next 20 years,
people at greatest risk of ulceration can easily be identified by careful
clinical examination of the feet. Education and frequent follow-up is
indicated for these patients.

6 As the world is facing
an epidemic of type 2 DM and an increasing incidence of type 1 DM, the
International Diabetes Federation had chosen to focus on the global burden
of diabetic foot disease in 2005. Data on diabetic foot in Iraq are scanty
and anecdotal.7

The aim of this study was to estimate the
prevalence of diabetic foot abnormalities among patients with type 2 DM and
the predictors of these abnormalities in Basrah.

PATIENTS AND METHODS

This was a cross sectional study of patients
attending the out patient clinic of two hospitals in Basrah (the General and
the Teaching) for the period from January to the end of December 2005.All
patients were having type 2 DM. Diabetes and hypertension was defined as
self-reported physician diagnosis of diabetes and hypertension.

8

For all patients history was taken including
age of the patients, smoking, job, and qualification (years of school
achievement). Social class calculated,and each patient was classified into
low , and other socioeconomic status ,based on the aggregate score of
education, occupation, and income.

9 They were asked
about duration of diabetes, medications, hospitalization and previous
diabetic foot problems. Subjects reporting smokingat
least one cigarette per day during the year before the examinationwere classified as smokers.All patients were examined for
weight, height, blood pressure, body mass index (BMI), calculated according
to Quetelet formula (weight in kilograms divided by heightin metres squared). Skin and peripheral pulsation were
examined. Both feet examined for structural foot abnormalities and skin
changes.

Structural foot abnormalities was defined as
follow: prominent metatarsal heads was defined as "any palpable plantar
prominences of the metatarsal site of the foot," and high medial arch (pes
cavus) as "an abnormally high medial longitudinal arch, which extends
between the first metatarsal head and the calcaneus.

4,10,11
Extension contracture at the metatarsophalangeal (MTP) joint with flexion
contracture at the proximal interphalangeal (PIP) joint is called hammer toe
while hyperextension of the MTP and flexion of the PIP and distal
interphalangeal (DIP) joint is termed a claw toe. Wasting was considered
when there is guttering between metatarsal heads.

Skin was examined for callus which was defined
as any hyperkeratotic formation due to shear stresses, usually in proximity
to a bony prominence.Dryness was assessed objectively, fissures were
included in any skin break that does not fit for the definition of foot
ulcer below .Nails changes includes any longitudinal ridging, fissuring,
separations, loss or thickening.

4,10,11Diabetic foot
ulcer was defined as any full-thickness skin lesion distal to the ankle
excluding minor abrasions, fissures or blisters.Interdigital fungal
infection (Tinea pedis) were considered as any white, macerated skin between
any web spaces.12

Metabolic control was according to American
Diabetes Association (ADA) with fasting plasma glucose of 90–130 (5.0–7.2)
mg/dL (mmol/L) and postprandial plasma glucose of less than 180 (< 10.0) mg/dL
(mmol/L).

13 Average of at least 3 reading were taken.
Diagnosis of peripheral neuropathy was according to quantitive assessment of
symptoms and physical finding according to others practice.14

Electrocardiography (ECG) was done for all and
urine examined for overt proteinuria. Proteinuria was diagnosed on the basis
of persistent frank proteinuria without erythrocytes or white blood cells in
urine. Electrocardiographic changes were considered according to practice.

15Heart failure diagnosis was based on history and physician
diagnosis with echocardiography.

Continuous variables were summarized as the
mean ± SD. Categoric variables were summarized as percentages. For
statistical analysis a chi-square test was used. A comparison of 2 means was
carried out with an unpaired Student t test. The level of significance was
set to be <0.05 throughout the analysis.

RESULTS

The total number of patients was 182 (80 males
and 102 females), with mean age of 56±8.4 year, and qualification of 2.5±4
year (Table-I). Duration of DM was 7.6±6.1 year and BMI of 25.6±2.5. Sixty
eight point six percent were non-employed and 77.4% were from rural area.
Most of them were from low social class (86.8%). Their treatment were diet
with oral hypoglycemic drugs in 73.6% and most of them were having
non-optimal glycemic control (94.5%) according to ADA. Hypertension was
present in 52.1% with heart failure in 20.8%, ECG changes in 63.7% and
proteinuria in 26.3%.

Structural foot abnormalities reported in
diabetic patients were prominent metatarsal heads in 36.2%, wasting in 11.5%
hammer toes in 10.9%, pes cavus in 5.4%, claw toes in 3.8%, and amputees in
2.1% (Table-II). While skin changes includes dryness of the skin in 17%,
fissures in the skin in 14.7%, callosities in 14.2%, Tinea pedis in 13.7%,
foot ulcer in 13.7% and nails changes in 7.1%. Peripheral neuropathy and
dermopathy were seen in 21.9% and 6% respectively.

Diabetic foot abnormalities were reported in
46.7% of patients (Table-III). Most of the patients were having more than
one abnormality. Varabiles predicts foot abnormalities ,that are
statistically significant were higher age, male sex, less school
achievement, longer duration of DM, higher BMI, smoking history, low social
class, insulin use, hypertesnion, heart failure and proteinuria.

DISCUSSION

Foot abnormalities were reported in 46.7% in
this study with mean age of 62±6.2 year. A population based study in
Minnesota showed that most diabetic patients have foot problems after age 40
and that the incidence of these problems increases with age.

16

The commonest structural foot abnormalities in
our study were prominent metatarsal heads (36.2%), followed by wasting
(11.5%), than hammer toes (10.9%) and claw toes (3.8%). These changes will
altered foot biomechanics which will increased risk of ulceration and
amputation.

17

In this study diabetic foot ulcer was present
in 13.7% of patients. This alarming high figure, comparable with figure of
(11.9%) in Algeria.

18 To complicate the story of
diabetic foot care in our area, we have no podiatry services available and
since amputations are preceded by foot ulcers in 75–85% of cases.6
These figures seems amazing, for the future amputation in our diabetics.

Commonest skin changes in this study were
dryness of the skin followed by fissures in the skin and callosities. The
explanation for these skin changes is autonomic neuropathy which is
reflected by decreased sweating, loss of skin temperature regulation, and
autosympathe- ctomy. Anhydrosis results in xerotic skin and predisposes skin
to fissures, cracks, and callus formation.

19

Predictors of foot abnormalities in this study
were higher age, male sex, less school achievement, longer duration of
diabetes mellitus, higher BMI, smoking history, low social class, insulin
use, hypertesnion, heart failure and Proteinuria. Similarly ADA consensus
group found that among persons with diabetes, the risk of foot ulceration
was increased among men, patients who had had diabetes for more than 10
years and patients with poor glucose control or with cardiovascular,
retinal, or renal complications.

17The benefit of
education in reducing diabeticfoot ulcers and lower-
extremity amputation is well documented.20 In a large
Italian case-control study possible risk factors for ulcer formation were,
male sex and lack of diabetes education.21While in
Jordan amputation of the lower limbs correlates with duration of diabetes,
poor glycemic control, smoking, neurological impairment, peripheral vascular
disease and microalbuminuria.22Lavery et al, in a
multivariate model, have also demonstrated that poor glucose control,
duration of diabetes over 10 years, and male sex are also significant risk
factors for foot ulceration.5

CONCLUSION

Diabetic foot abnormalities were reported in
46.7% of patients. Variables that predicts foot abnormalities, that are
statistically significant were higher age, male sex, less school
achievement, longer duration of diabetes mellitus, higher BMI, smoking
history, low social class, insulin use, hypertesnion, heart failure and
proteinuria. We are calling for organization of the foot-care service in
Basrah and education which should be tailored to the patient’s understanding
and social background to mange an epidemic of foot abnormalities expected to
be seen in the near future.

Limitations of the study: The sample size
appears to be small to generalize the results for whole Basrah city.
However, in view of the prevailing conditions in Iraq, this study highlight
the high prevalence of diabetic foot abnormalities requiring appropriate
measures and establishment of foot care services.